Specialist Tutoring Registration Form

    Tutoring runs at the Centre only

    Personal Details
    Please complete the details of your child wishing to participate in tutoring (a separate form must be filled in for each child).

    Child’s full name (Surname and First Name)

    Date of Birth:

    School

    Class

    Parent/Guardian’s Full Name

    Parent’s Email

    Parent’s Phone Numbers

    Address

    Tutoring (Please Tick)

    Type of Tutoring required One-to- OneTwo-to-One

    No. of Times a Week: Three times a weekFive times a week

    Preferred days of the week. (This is subject to availability) MondayTuesdayWednesdayThursdayFriday

    Preferred Time: 2-3pm3-4pm4-5pm5-6pm

    Booster Classes (Please Tick)

    Types of Booster Classes Comprehension Booster ClassMemory Booster Class One-to- OneTouch Typing

    Total No. of Sessions ((Minimum of 10 Sessions ):

    No. of Times a Week: Three times a weekFive times a week

    Preferred days of the week. (This is subject to availability) MondayTuesdayWednesdayThursdayFriday

    Preferred Time: 2-3pm3-4pm4-5pm5-6pm

    Parental Consent

    The name given above will be used as the main form of contact, however, in case of an emergency please can you provide a second contact name and number.

    Emergency Contact’s Full Name :

    Emergency Contact’s Telephone Number(s):

    Does your child have any medical conditions we should be aware of? For example, asthma, epilepsy etc. If so, please give details.

    Terms and Conditions
    I agree for my child to receive tutoring at Dyslexia Nigeria.
    It is my responsibility to arrange the transport of my child to and from their tutoring session.
    I agree to respect my allotted time and to ensure my child arrives and leaves promptly for their sessions.
    I agree to inform Dyslexia Nigeria of any changes to the information above.
    All tutoring takes place in Dyslexia Nigeria Centre Mon-Fri, 2-6pm.
    I accept that Dyslexia Nigeria does not endorse and cannot take responsibility for anything which may happen during sessions arranged for other times or outside of the approved Dyslexia Nigeria Centre.


    I agree to the terms of DN's tutoring and give permission for my child to attend.

    I agree to photos being taken of my child as a record of the sessions and for use in funding applications, future publicity and on the DN website.

    Name